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be a low continued cry which is almost a in the apparatus used in nursing) or that moan; but this cry occurs too late to be of nursing caused pain. The cry of acute any special value.
gastro-enteric infection is of a restless type, Short violent cry may be due to several with intervals during which the infant factors:
sleeps quietly, but these last only a few (a) Increased upon pulling at the ear
minutes. In pneumonia the cry is apt to or by movements which affect the head sug- be short and catchy. In meningitis we may gests the probability of inflammation of the encounter a sharp, piercing, nocturnal cry,
but this is true also of chronic bone disear. In the presence of an acute inflammation of the ear the mere act of sucking
In marasmus there is a continual will cause pain and this type of crying.
whine; the child is seldom at ease.
If the infant cries when it is handled and There is usually some elevation of tempera
at other times seems to be comfortable, it ture.
is indicative of infantile scurvy. (b) With a shrill character and follow
Any vigorous crying, no matter what its ing or associated with the act of coughing
type, would immediately exclude such disor sneezing, it points to acute pleurisy.
eases as atelectasis, advanced peritonitis, (c) When very piercing in character,
pleuro-pneumonia, or croup. very sudden in its onset, and almost sim
And so if I had time, I might go on and ultaneous with the act of vomiting and as
mention many things which are great aids sociated with marked prostration quickly
to the examiner who is alive to the elofollowing, it should lead to an examination
quence of the infant. for intussusception.
And when we come to consider those in(d) While in a somnolent condition it is
dicators of the pathological condition ; inevidence of hydrocephalus or hydroceph
dicators which are not subject to the inaloid.
fant's will or choice, their name is legion. (e) Occurring during defecation (due
Even though the eloquence of the infant to actual pain) or just previous to the
moves the mind to a clearer appreciation of act (dread of pain), and associated with
the disease present or impending, and obpersistent constipation, it is almost certainly servation seems to indicate that a certain due to fissure of the anus. The same thing pathological process is present, the attitude happening during the act of urination indi
of the physician should be two-fold. First, cates that there is a spasm of the bladder, for the infant's welfare, the deductions the passing of some fine calculi, or it is oc- drawn from observation must be confirmed casioned by phimosis. The administration by the most careful examination. And, of appropriate treatment quickly clears up second, having drawn a conclusion, the the first, the examination of the diaper physician for his own good, should quesshows evidence of the second, and exami- tion himself as to why he arrived at such nation of the penis clears up doubt as to conclusions. This double examination must the latter.
surely act as a stimulant to personal enCrying which occurs only when food is deavor and the finer appreciation of disease offered would indicate that the child was in the infant. unable to nurse (and this might be due to As physicians living in an age when causes in the nose or mouth or to faults scientific achievement and activity seem to be at their height and when the whole retroflexions which are not complicated by medical world is alive with the stimulating elongatio colli, by cystocele, by descent of expectancy of impending discovery, we are the uterus or by descent of the vaginal walls. prone to be negligent of the smaller things. Then the simple operation of vaginal fixa
And yet this may be said to be one of tion usually suffices except in those cases the great dangers of a medical career;
where the anterior vaginal wall is conthe trusting in special occasions. We are genitally a short one, in which cases vaginal apt to think that conspicuous occasions, un
fixation is contra-indicated. usual experiences with disease and the If in the above mentioned class of cases wrestling with big problems have most to of retroversions or retroflexions complido with the advancement of our profession. cated by elongatio colli, by cystocele, by deIn this we are wrong. The commonplace scent of the uterus, etc., the simple operaday, the doing of the ordinary things, the tion of vaginal fixation is done the operaregard for everyday experience; these are tion fails of its best results as can be seen the things which try out and prove the from Figures i and 2. man. The real test comes during the com- Figure i shows the fixation sutures which monplace experience with disease and it is are to unite the anterior wall of the uterus this experience that fits one for the to the anterior vaginal wall in the simple mountain-top attainment.
operation of vaginal fixation. 42 Gates Ave., Brooklyn, N. Y.
Fig. 2 shows the sutures tied and the longitudinal and transverse incisions in the
act of being closed by running catgut suSOME POINTS OF IMPORTANCE IN
ture. THE PERFORMANCE OF VA
Figure 2 shows, in an exaggerated form, GINAL FIXATION.
the lack of tautness in the anterior vaginal
wall in the case of simple vaginal fixation SAMUEL WYLLIS BANDLER, M. D., done for cystocele with descent. The imAdjunct Professor of Diseases of Women in the portant point to be noted however, is the New York Post-Graduate Medical School
faulty position of the cervix. (The cervix and Hospital.
is shown for purposes of demonstration furNew York City.
ther out beyond the vulva than is actually Vaginal fixation of the uterus attaches the case). This demonstrates that the lack the fundus uteri to the anterior vaginal of tautness in the anterior vaginal wall is wall and places the bladder on the posterior not alone responsible for the position which wall of the uterus.
the cervix has assumed. The trouble is In order to perform this operation to the that the uterus is too long, hence the simgreatest advantage to the patient, it is nec- ple operation does not throw the cervix essary that the fundus should be well up high up and far back when, as is depicted behind the symphysis and that the cervix in this drawing, we are dealing with an enshould be thrown high up and as far back as larged or elongated uterus, a uterus which possible toward the hollow of the sacrum. has descended. It is necessary to overcome The cervix takes this position when vaginal this obstacle when dealing with ptoses of fixation is done to correct retroversions or the uterus, when the uterus is enlarged and
Fig. 1. essary in the major degrees of ptosis and it is necessary to make a taut anterior vagin the case of total prolapse of the uterus. inal wall to which the fundus is to be fixed.
FIG. 2. of the two flaps produced in the anterior an amputation of the cervix has been done. vaginal wall after separation of the blad- The accompanying illustrations show the der.
two methods of accomplishing these steps.